THE HEALTH GAZETTE

The prostate gland is located at the base of the bladder and it is about the size of a walnut. It secretes a milky fluid that is a component of semen. Since the gland is located directly in front of the rectum, it can be felt by performing a rectal exam. Prostate cancer is the most common cancer other than skin cancer in men in the United States. The American Cancer Society estimates that 200,000 new cases will be diagnosed in 1994. This is up from the 165,000 cases that were reported in 1993. It accounts for 21% of all newly diagnosed cancers in males. Since people are living longer, the incidence of prostate cancer will increase proportionately. Approximately 35,000 men die of prostate cancer every year. That makes it the second leading cause of cancer deaths among males. With the recent deaths of actor Telly Savalas and musician Frank Zappa from prostate cancer, there has been a surge in public interest of this disease.

Having a family history of prostate cancer is the most significant risk factor. The incidence of prostate cancer is also increased in African-Americans. Environmental factors may contribute to the development of prostate cancer. There is an increased incidence in persons migrating to the United States from areas with a low incidence of prostate cancer. Certain industries are associated with an excess of prostate cancer. These include workers that are exposed to cadmium, workers in tire and rubber manufacturing, farmers, mechanics, and sheet metal workers.

Approximately 60% of patients have localized cancer when first diagnosed. Most of these patients will be asymptomatic or have difficulty urinating. If the cancer has spread, patients may present with bladder outlet obstruction or bone pain from spread of the cancer to the bones. Patients also may present with renal failure from obstruction of the urethra. Digital rectal exam is the gold standard for detection of prostate cancer. Fifty percent of palpable nodules will be found to contain cancer. Transrectal ultrasonography is used for the evaluation of a prostate nodule. It is also used to better define what area to biopsy. This procedure involves inserting a probe into the rectum and obtaining an ultrasound of the prostate gland. The biopsy can then be directed at any abnormalities on the resulting picture.

Screening for prostate cancer has become somewhat controversial. The American Cancer Society recommends a yearly digital rectal exam starting at age 40. They have recently added the recommendation to get a yearly prostate specific antigen(PSA) blood test beginning at age 50. The PSA test measures a protein in the blood that increases with the development of prostate cancer. Unfortunately this test is far from perfect. There are many false positive as well as false negative results. There is quite a bit of disagreement on this recommendation. We do not know whether early detection will reduce mortality. At least 30% of men over 50 years of age have definite evidence of prostate cancer, yet only a small fraction of these cancers will progress to cause death. There is presently no way to predict which cancers will progress and spread. A recent article in The New England Journal of Medicine concluded that watchful waiting is a reasonable option for men with localized early prostate cancer, especially if their life expectancy is less than 10 years. Men that are in their fifties or sixties, are likely to improve their life expectancy with treatment. Microscopic evaluation of the biopsy specimens can be helpful in classifying the cancer as to its potential for spread.

There are presently several different options for treatment. Approximately 21% of patients have their prostate gland removed(prostatectomy), while 23% have radiation therapy. Hormone therapy is used in 19% of patients while a combination of several different treatments is utilized in 8%. Twenty-nine percent of patients choose no treatment. Younger patients are more likely to undergo a prostatectomy. The overall 5-year survival rate is between 50% and 60%. If the cancer is confined to the prostate gland, then the 15-year survival after a prostatectomy is equivalent to a person that is the same age, but doesn't have prostate cancer. A prostatectomy leaves at least 30% of patients impotent and 1%-2 % incontinent. Radiation therapy has an impotence rate of about 25% and an incontinence rate of almost zero. Unfortunately, some cancer is left behind about 10% of the time in both methods.

1. Chodak G, et al. Results of Conservative Management of Clinically Localized Prostate Cancer. N Engl J Med 1994 330: 242- 248.

2. Holleb A, et al. Cancer of the Prostate. Clinical Oncology(ACS) 1991 pp 280-283.

3. Littrup P, et al. The Benefit and Cost of Prostate Cancer Early Detection. CA, May / June 1993 pp 135-149.

4. Mettlin C, et al. Trends in Prostate Cancer Care In The United States,1974-1990: Observations From The Patient Care Evaluation Studies Of The American College Of Surgeons Commission On Cancer. CA, March / April 1993 pp 83-93.

5. Carey B. The Prostate Predicament. Health May / June 1984 pp 101-104.

The information provided above is offered as a community service about health-care issues and is not a substitute for individual consultation. Advice on individual problems should be obtained from your personal physician. This information is based on research by the author and represents his interpretation of the literature.